Report Of Medical History Form
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1
2O O U U THWEST
THWEST
H
S
EALTH
ERVICES
REPORT OF MEDICAL HISTORY
M I N N E S O T A
M I N N E S O T A
S T A T E
S T A T E
U N I V E R S I T Y
U N I V E R S I T Y
As a student, it is your responsibility to provide an accurate past medical history.
All information is held confidentially within Health Services at Southwest Minnesota State University.
Please complete before entering college.
Last Name (Family Surname)
First Name (Given-Personal)
Middle Name
Home Address (Number and Street)
City or Town
State
Zip
Country
*Date of Birth (MM/DD/YY)
Emergency Contact Name and Relationship
Home Telephone
Emergency Contact Address
Business Telephone
Gender: Male [
] Female [
]
*Social Security Number of Student
*Many colleges/universities use Social Security numbers for student identification purposes on student records. Providing your Social Security number, gender, and date of birth is voluntary.
If you do not provide this number, this information will still be processed. This data is requested for purposes of administration, program evaluation, and consumer and alumni data. Your
number also may be used to create summary information about MnSCU programs through data matches with other state agencies.
SEMESTER ENTERING:
Circle Term: Fall
Spring
Summer Session I or II
Year: 20____
HAVE YOU OR ANY OF YOUR RELATIVES HAD ANY OF THE FOLLOWING?
AILMENT
YES NO
RELATIONSHIP
YES NO
RELATIONSHIP
AILMENT
Tuberculosis
Diabetes
Kidney Disease
Heart Disease
Arthritis
Stomach Disease
Asthma
Hay Fever
Seizure Disorder
Cancer
PERSONAL HISTORY: PLEASE ANSWER ALL QUESTIONS.
Comment on all positive answers in the space on the back side of this sheet.
HAVE YOU HAD:
HAVE YOU HAD:
HAVE YOU HAD:
NO
YES
NO
YES
NO
YES
HAVE YOU HAD:
YES
NO
Insomnia
Pain/Pressure in Chest
Gallstones
Chicken Pox
Malaria
Frequent Anxiety
Chronic Cough
Recurrent Diarrhea
Depression
Gum/Tooth Trouble
Heart Palpitations
Rupture, Hernia
Nervousness/Worry
High/Low Blood Pressure
Recent Weight Gain
Sinusitis
Recurrent Headaches
Rheumatic Fever
Recent Weight Loss
Eye Trouble
Recurrent Colds
Heart Murmur
Dizziness, Fainting
Ear/Nose/Throat Trouble
Surgery:
Joint Disease
Weakness, Paralysis
Head Injury with
Unconsciousness
Appendectomy
Joint Injury
Seizures
Tonsillectomy
Hay Fever, Asthma
“Trick” Joint (
Venereal Disease
Knee, Shoulder)
Hernia Repair
Tuberculosis
Back Problems
Albumin/Sugar in Urine
Immunization Data:
Shortness of Breath
Tumor or Cyst
AIDS or HIV
(Most recent date)
Allergic Reactions:
Menstrual History:
Cancer
Measles/Mumps/Rubella Year:_________
Tetanus/Diphtheria
Year:_________
Penicillin
Jaundice
Age at Onset
Hepatitis B
No Yes/Year:_________
Sulfonamides
Stomach Problems
Irregular Periods
Meningococcal No Yes/Year:_________
Serum
Intestinal Problems
Severe Cramps
HPV
No Yes/Year:_________
Foods (which)
Urinary Problems
Excessive Flow
Varicella
No Yes/Year:_________
Gallbladder Trouble
Other:
Other:
Recurrent Infections
Height: ________Inches (________Centimeters)
Weight: ________lbs. (________Kilograms)
Continue on the other side.
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Parent category: Medical